Background
Caesarean section can be a life-saving intervention during deliveries where the mother or baby is at significant risk of adverse outcome. Many high maternal mortality regions struggle to provide safe and timely caesarean sections in such circumstances [
1], yet women worldwide are increasingly undergoing procedures for which there is little clinical justification [
2]. These ‘unnecessary’ caesarean sections have been associated with increased maternal risk of severe morbidity and even mortality [
3,
4]. High rates of caesarean sections also have economic repercussions on patients and their families, as financial costs for the procedure are higher than for vaginal birth and a longer period of hospitalization is necessary. This is especially true in low- and middle-income countries where medical care is often purchased ‘out-of-pocket’ [
5]. It is widely accepted, including by the World Health Organization (WHO), that caesarean deliveries should only be undertaken where medically necessary [
3,
4,
6,
7].
Caesarean section rates vary widely across the globe, ranging from as low as 1% in parts of Sub-Saharan Africa to 30% in the USA and 45% in Brazil [
5]. Following debate over the most appropriate rates of caesarean sections at national and regional levels, the WHO issued a statement in 2015 recommending that every effort should be made to provide caesarean sections to women
in need, rather than striving to achieve specific population-level rates [
6]. At the facility-level, it is recommended the ‘Robson classification’ system be used as it allows for comparison of caesarean rates within and across different risk groups of women [
6,
8].
A wide variety of explanations have been proposed for rising caesarean rates, ranging from medical and demographic factors to changing patient expectations and provider practices. Repeat caesareans are an important contributor to high rates, as previous caesarean delivery pre-empts need for the procedure in successive deliveries. The risk of morbidity increases with each procedure [
9].
Studies in multiple settings have found high rates of caesarean sections associated with non-medical factors. Higher caesarean rates are consistently associated with delivery by private providers, and thus have often been linked to financial incentives [
10‐
19]. Research in private facilities has also shown that both planned and unplanned caesarean sections, including some emergency ones, are more likely to occur on weekdays or during daylight hours [
20‐
22]. It is possible that elective procedures account for many of these daytime caesareans, and that some emergency caesareans may be held over until day staff come on duty, rested and alert, to ensure better outcomes. However, these studies [
20‐
22] also suggest that physician factors, including convenient timing of deliveries and desire for increased leisure time, are significant predictors of caesarean sections. Obstetricians’ fears of complaints and legal action have also been indicated as determinants of caesarean delivery [
23‐
27], and it has been suggested that providers perceive fewer risks, both legal and medical, associated with caesarean versus vaginal deliveries [
4,
26]. Another concept frequently cited in literature is the influence of patient-related factors, such as maternal request for caesarean section. Maternal demand could be motivated by a number of non-medical factors including fear of vaginal birth, need for control, and cultural acceptability of the procedure [
28]. One study in the UK suggested that doctors perceived maternal request as the most important factor driving caesarean rates, although few actually reported receiving a large number of requests or performing caesareans on request themselves [
26].
The Indian context
India has made significant progress in improving maternal health, with the current maternal mortality ratio almost half of what it was in 2000 [
29]. As mortality rates fall and increasing numbers of women gain access to formally trained maternity care providers, improving quality of care is becoming a priority for policy-makers. Indeed, some data suggest that quality of care is generally poor, though variable, in both the public and private healthcare sectors [
30]. The private sector currently accounts for more than 70% of primary healthcare in India following rapid growth in recent decades [
31]. This expansion has been accompanied by very little regulation or quality assurance, and insufficient standardisation of treatments, protocols and pricing. Private medical insurance is becoming increasingly common, although a large proportion of people still pay for care ‘out-of-pocket’ and are vulnerable to financial impoverishment if they require expensive surgeries or medication [
32].
Private providers play a significant role in maternity care in India, accounting for 48% of institutional childbirths in urban areas and 24% in rural areas [
31]. In Delhi, as in many other large cities in India, the vast majority of deliveries in the private sector are undertaken by obstetricians, who typically operate fee-for-service solo practices. There is very little practice of midwifery in urban hospitals and obstetricians often assume the role of the primary carer during deliveries, with limited support from other healthcare staff, especially midwives [
33]. The size and structure of private sector facilities varies widely, from small nursing homes to large hospitals that are part of multi-national corporate chains [
14].
Although the overall rate of caesarean deliveries in India is around 17%, rates have risen rapidly over the last ten years from 8.5% in 2005–06 to 17.2% in 2015–16 [
34], driven particularly by increases in the private sector and in urban areas. Data collected over 2 years in the city of Chennai in south India indicated a caesarean rate of 47% in private healthcare [
18]. Other studies have reported that women in the states of Kerala, Goa, Andhra Pradesh, Bihar, Gujarat, Karnataka, Punjab, Uttar Pradesh, Delhi, Maharashtra, and Tamil Nadu are far more likely to deliver by caesarean if they receive private care [
11,
13,
15]. A community-based household survey indicated that 54% of women delivering in the private sector in Delhi underwent caesarean section, compared with a 24% rate in the public sector [
14]. Although rates were not classified according to women’s risk-status, this figure appears to indicate overuse of the procedure.
A small number of studies have presented data that begin to explain
why caesarean section rates in the Indian private sector are higher than in the public sector. An analysis of supplier-induced demand in Madhya Pradesh and Gujarat [
35] found that direct economic incentives led to increases in caesarean rates whilst financial disincentives led to decreasing rates. This suggests that private obstetricians induce maternal demand for caesarean section due to profit-making motives. Other studies have identified a positive correlation between maternal educational level and likelihood of caesarean delivery in private facilities, suggesting that maternal demand also plays a role, particularly amongst women with a higher level of education [
15,
17]. Despite these findings, one of the studies [
15] suggests that rising rates of caesarean delivery are more a result of supply factors (relating to the obstetrician) than maternal demand.
A number of studies reporting high rates of caesarean sections in the private healthcare sector in India have hypothesized that these reflect financial incentives, time pressures, the custom of solo practice, fear of litigation, maternal request, and use of intensive foetal monitoring [
13,
14,
18]. However, it was not within the remit of the studies to test these hypotheses, and so the evidence remains lacking. No studies have explored providers’ perspectives of the reasons for high caesarean rates in their private practices in India. The small quantity of data generated in other settings, especially high-income countries, may not be applicable to the Indian private sector. Our study sought to explore the perspectives of private healthcare professionals involved in maternity care in Delhi on reasons for high caesarean section rates, and solutions to reverse the trend of high rates in private maternity care in Delhi. The study is among the first to explore provider-side perspectives on this issue in the Indian setting.
Methods
Study setting
The study was located in Delhi and its neighbouring suburbs of Gurgaon and Ghaziabad, all in the National Capital Region (NCR) of India. Maternity care is delivered by a wide range of private and public facilities that vary greatly in size, structure, and staffing arrangements in these three settings. There are more than 560 private hospitals and nursing homes in Delhi alone [
36]. Women of high socio-economic status are more likely to pay for private maternity care, with more than 80% attending private facilities. A substantial proportion of middle and low socio-economic status women (40 and 16%, respectively) also opt for private maternity care. Caesarean sections are more common in private facilities, where the rate is 54% compared with 24% in the public sector [
14]. Our study focused on private maternity care providers in this setting. We collaborated with a private medical hospital and research institute based in South Delhi.
Study design
Fourteen in-depth qualitative interviews were conducted during July and August 2015. We approached key informants who could offer insights from the perspective of a private sector maternity care provider. To get an all-round providers’ perspective, we purposively selected practicing obstetricians and a small number of other healthcare professionals with involvement in maternity care - two paediatricians, the manager of a private maternity hospital and a ‘doula’ or birth companion, who is professionally trained to provide physical, emotional and educational support to the mother. This gave us the opportunity to compare and contrast the perspectives of obstetricians with those of other professionals with good knowledge of the sector.
The majority of study participants worked in South Delhi, with an additional participant working in East Delhi and two in other cities in the NCR, Gurgaon and Ghaziabad. As the sector is highly diverse, we selected providers from secondary and tertiary facilities of different sizes, with capacity for performing caesarean sections: small hospitals or nursing homes (< 50 beds), medium-sized hospitals (50–150 beds), and a large corporate hospital (> 150 beds). These included a mix of multi-specialty and super specialty private hospitals where a normal delivery can cost upwards of INR 40,000 (US$ 615), and a caesarean section in a super luxury room can be priced as high as INR 12,00,000 (US$ 18,461). These were amongst the more high-end private hospitals in the NCR, serving the wealthiest socio-economic sections of the population, who would typically seek only private sector maternity care.
With the help of our collaborating research institute, we drew up an initial list of 19 potential respondents and contacted them for interviews. Ten agreed to an interview during the period that the primary researcher was available, and with the help of these respondents, we identified and interviewed an additional four who agreed.
The interviews were conducted using an interview guide that explored participants’ professional status and background, perceptions of current caesarean section rates in the private sector, awareness of guidelines regarding rates, reasons they attributed to high rates, and their suggested solutions for reducing rates.
Confidentiality was maintained by conducting the interviews in private rooms at participants’ workplaces or homes. Interviews were audio-recorded where permission was given. In the case of three participants where permission was not given, detailed hand-written notes were taken. All interviews were carried out in English by a single interviewer.
Analysis
All audio-recorded interviews were transcribed. Transcripts and interview notes were coded manually using a coding frame developed both from concepts that emerged in the data and those found in the existing literature, for example financial incentives. Data were organised into matrices for each major topic to help systematize analysis, identify patterns in the data, and compare participants. A final list of key themes and sub-themes emerging from interviews was identified.
Discussion
The present study identifies a number of important factors that may be driving high rates of caesarean sections in the private healthcare sector in Delhi and its neighbourhood. The rates reported by some respondents for facilities where they practiced varied from 15 to 50%, and a small number reported rates as high as 90%. As self- or facility-level auditing of caesarean sections was not commonly practiced in these facilities, these rates may be considered as estimates rather than precise figures. Even so, the figure of 50% is comparable to rates reported by two household surveys in Delhi: the National Family Health Survey-4 [
34] that reported 43% caesarean births in the private sector and another household survey conducted at a similar time [
14] that found 54% caesarean section births in the private sector. The higher rate of 90% reported by a small number of our respondents could be more facility specific and indicative of the substantial variation likely to exist across facilities. Similar variation can be seen in reported rates ranging from 50 to 99% in a study of private health facilities providing delivery care in the state of Uttar Pradesh, which borders Delhi [
37].
The respondents we interviewed were generally of the opinion that unnecessary use of caesarean sections was an important issue in this sector. Key contributors were identified as: obstetrician convenience and time pressures, particularly owing to the high prevalence of solo obstetric practice; a perception of caesarean deliveries as the ‘safe’ option, both in terms of maternal health and protection from litigation; and financial pressures associated with running a successful clinic, or working for a commercial hospital. Other important reasons for high rates of caesarean deliveries included system-related factors, especially the lack of comprehensive guidelines tailored to the Indian setting, and lack of well-trained support staff such as midwives, as well as patient-related factors such as maternal and family related fears and demands. Interestingly, none of our respondents mentioned emergency referrals from smaller, more poorly-equipped private facilities or from government facilities as an important reason for the high caesarean rates. In a recent study in Uttar Pradesh [
37], emergency referrals for caesarean sections were commonly reported by secondary and tertiary private facilities located on the outskirts of big cities and in smaller urban centres. Our study sample was quite different from these types of peri-urban facilities. Our respondents were all located within a metropolis, where most delivery facilities, private as well as public, have the capacity for performing caesarean sections and do not need to refer frequently. Moreover, the clientele at these facilities belonged to the wealthiest socio-economic groups who could afford pregnancy and delivery care at the best equipped private facilities from the very beginning.
Although respondents gave a variety of reasons for high caesarean rates, many of these can be retraced to the commercial nature of private sector practice that incentivises growing practices even to the point that time pressures interfere with the ability to provide quality care. Obstetricians must maintain their patient loads in order to run commercially viable practices, leading to immense pressures on their time. They must protect their patients from any adverse outcomes, and themselves from litigation. It is not possible to monitor every delivery to its normal conclusion, and so obstetricians may opt for caesarean deliveries in order to ensure patient safety and sufficient time to attend to all of their patients. As a result, caesarean section has come to be considered as the ‘safe’ option, in spite of the associated risks. A culture amongst obstetricians of performing caesarean sections, where ‘caesarean is seen as the new normal’, reinforces this perception and may prevent providers from recognising high caesarean rates as abnormal or harmful. Furthermore, inadequate support systems, including very limited practice of midwifery in India, increase time pressures on obstetricians and the difficulty of decision-making regarding deliveries.
Maternal and family requests for caesarean section were also identified as a driver of caesarean rates. Providers perceived a culture where caesarean sections are considered an ‘easy’ option among women using private sector facilities. The apparent frequency with which obstetricians fulfil patients’ requests for caesarean section reflects the provider-consumer type exchange between doctors and patients due to the commercial nature of their relationship. Doctors may feel obliged to fulfil patients’ demands or refrain from taking a hard line during patient counselling in order to avoid losing that patient. Our data suggest that some women who request caesarean deliveries receive insufficient counselling regarding the associated risks, likely due to the pressures on obstetricians’ time. Respondents did, however, identify physical factors, such as women postponing pregnancy until later in life or being overweight because they were leading more sedentary lifestyles, as a cause of rising caesarean rates, particularly amongst the high socio-economic status women who use private healthcare.
A lack of guidelines and regulation regarding caesarean sections amplify the effects of rising caesarean section rates, as obstetricians and institutions are not held accountable for their rates. The Indian government’s most recent guidelines for dealing with obstetric complications were issued in 2005. These detail the complications for which a caesarean section may be necessary, but no thresholds for caesarean section are given and few associated risks are mentioned [
38].
The solutions that respondents offered for reducing caesarean section rates reinforce these explanations. They suggested that the level of support from junior and nursing/midwifery staff be improved, by either expanding the roles of support staff or encouraging small groups of obstetricians to work in ‘shared practice’, providing professional support to one another where necessary. Expanding the role of midwives to be the primary carers during normal deliveries, with support from obstetricians only when complications occur, could significantly reduce the time pressures on doctors and thus help avoid unnecessary caesareans. Unfortunately, midwifery remains an under-developed and under-recognised profession in India [
33], with neither legislative support nor training standards for independent midwifery. The currently available training in midwifery, which is limited to a few months and combined with more general nursing training, has been found inadequate for preparing confident and competent midwives [
39]. Greater policy support is required to promote midwifery in India, although this is likely to be met with initial resistance from providers and patients who are accustomed to doctors being present throughout the delivery. Other suggestions were that comprehensive caesarean section guidelines be made available from an Indian medical body, and that individual and institutional caesarean section rates undergo auditing and regulation. Some form of peer review within the sector, or regulation by an external body, could help to improve obstetricians’ awareness of their own rates and incentivise them to only perform procedures in cases where they are truly necessary.
The present study adds depth to the current understanding of high caesarean rates in the Indian private sector. Our findings support results from previous studies both in Indian and non-Indian settings, which emphasise obstetrician time and convenience factors [
20‐
22], fear of litigation [
23‐
27], financial incentives [
10‐
19], perceptions of low risk [
4,
26], and maternal demand [
26,
28] as important reasons for high caesarean section rates. In addition, the present study identifies some previously undocumented factors that may contribute to high caesarean rates in the Indian setting: a lack of appropriate guidelines on caesarean sections, and the culture of private sector obstetricians working in solo practice, often with insufficient support systems, particularly well-trained midwives. Furthermore, our analysis highlights the ‘missing’ link between caesarean sections and obstetricians’ high practice volumes as a result of financial incentives in the private sector.
Limitations
The small sample size of this study, due to resource constraints and the difficulties in accessing busy obstetricians and other maternity healthcare providers, limits its generalisability. Our sample was also mostly limited to the higher end obstetricians and multi-speciality/super-specialty private hospitals that cater to wealthier, urban clients that can afford to pay a high fee for institutional deliveries in big city hospitals. The situation in smaller, less expensive private hospitals in peri urban and rural areas is likely to be quite different and needs to be explored through other studies. Another limitation was that we could not access any documented data on caesarean rates from the facilities and, therefore, the rates we present here are reported estimates. However, it is unlikely that this information would have been available in many cases, as the respondents themselves reported that little self-auditing occurred amongst providers. We have also shown that the estimates are comparable to rates reported in the published literature. Finally, we did not interview any patients in this study, as our focus was on providers’ perceptions. Patients’ perceptions could be very different, and especially useful for understanding the extent to which maternal requests play a role in this setting. Nonetheless, the providers’ perceptions reported in this article are a valuable addition to the literature. We have reached out to an important and challenging group of providers and gathered rich and in-depth insights on a sensitive topic that will be useful for exploring caesarean reduction strategies, and designing further research around this important topic.
Conclusions
A complex relationship exists between high caesarean rates and the commercial nature of the private sector. Although there may be no direct link between providers’ decisions for a caesarean section and financial gain, obstetric practice in the private sector is dependent on maintaining high patient loads. This can lead to doctors taking on more patients than they can feasibly manage, and opting for caesarean deliveries in order to ensure patient safety, as well as protection from litigation.
Reducing high rates of caesarean deliveries in the Delhi private sector will depend on the introduction of comprehensive caesarean section guidelines, including indications and thresholds for which the procedure should be performed, and public disclosure of the caesarean rate for individual obstetricians and hospitals. However, regulations and guidelines may be insufficient without a parallel strengthening of professional midwifery support for obstetricians, before, during and after childbirth, and improved patient counselling and awareness. As India’s most prominent obstetric body, the Federation of Obstetrics and Gynaecological Societies of India could play an important role in steering a comprehensive and sustainable caesarean reduction strategy in the higher end private sector in India.